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Start Preamble

AGENCY:

Centers for Medicare and Medicaid Services, HHS.

In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (CMS)), Department of Health and Human Services, is publishing the following summary of proposed collections for public comment. Interested persons are invited to send comments regarding this burden estimate or any other aspect of this collection of information, including any of the following subjects: (1) The necessity and utility of the proposed information collection for the proper performance of the agency's functions; (2) the accuracy of the estimated burden; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

1. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Hospital Request for Certification in the Medicare/Medicaid Program.

Form No.: CMS-1514 (OMB# 0938-0380).

Use: Section 1861 of the Social Security Act requires hospitals and critical access hospitals to be certified to participate in the Medicare/Medicaid program. These providers must complete the “Hospital Request for Certification in the Medicare/Medicaid Program” form in order to be certified or recertified.

Frequency: Annually.

Affected Public: Business or other for-profit, Not-for-profit institutions.

Number of Respondents: 6,300.

Total Annual Responses: 2,000.

Total Annual Hours: 500.

2. Type of Information Collection Request: Extension of a currently approved request.

Title of Information Collection: Hospice Survey and Deficiencies Report Form and Supporting Regulations at 42 CFR 418.1—418.405.

Form No.: CMS-643 (OMB# 0938-0379).

Use: In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

Frequency: Annually.

Affected Public: State, local or tribal government.

Number of Respondents: 2,339.

Total Annual Responses: 475.

Total Annual Hours: 1,188.

3. Type of Information Collection Request: Extension of a currently approved collection.

Use: The CLIA Adverse Action Extract will be used by CMS surveyors (State health department, and other CMS agents) to report to regional staff and record the adverse actions imposed against a laboratory. The form will also serve to track dates of the imposition of adverse actions, date on which a laboratory corrects deficiencies, and all appeals activity.

Frequency: On occasion, Biennially.

Affected Public: State, local, or tribal government.

Number of Respondents: 52.

Total Annual Responses: 1573.

Total Annual Hours: 786.

4. Type of Information Collection Request: Revision of a currently approved collection.

Title of Information Collection: Authorization agreement for electronic forms transfer.

Form No.: CMS-0588 (OMB# 0938-0626).

Use: The information is needed to allow providers to receive funds electronically in their bank accounts.

Frequency: On occasion.

Affected Public: Business or other for-profit, Not-for-profit institutions.

Number of Respondents: 10,000.

Total Annual Responses: 10,000.

Total Annual Hours: 1,250.

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS's Web site address at http://cms.hhs.gov/​regulations/​pra/​default.asp, or e-mail your request, including your address, phone number, OMB number, and CMS document identifier, to Paperwork@hcfa.gov, or call the Reports Clearance Office on (410) 786-1326. Written comments and recommendations for the proposed information collections must be mailed within 60 days of this notice directly to the CMS Paperwork Clearance Officer designated at the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development and Issuances, Attention: Dawn Willinghan, Room: C5-14-03, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.